Sandy Flynn didn’t realize she was transgender until she was 60 years old. She had married as a man, and although they never had children, Flynn kept her urge to be female hidden from her wife until the divorce.
When she decided that she wanted to transition, or have gender reassignment surgery, she discovered that the procedure could cost up to $30,000 in the United States. Not having those kinds of resources, and knowing her surgery wouldn’t be covered by her health insurance, Flynn had the surgery in Thailand for only $9,000. The surgery went well, she says, but the Thai doctors failed to give her healing instructions.
“They didn’t tell me anything about what to do after,” says Flynn. “I got severely infected.”
Thousands of transgender people across America face similar problems when they transition. The gender reassignment surgery is expensive, but in order to transition completely, many other operations are often necessary.
Although the American Medical Association and the American Psychological Association have deemed transition-related surgeries medically necessary, most health insurance companies have built-in exclusions that prevent coverage for these surgeries, as well as coverage for hormones and other transition-related care. As a result, many transgender people lack the resources to pay for surgeries and hormones, so instead, they turn to black-market surgery or silicone injections, all of which carry extreme health risks.
According to the Human Rights Campaign, a lesbian-gay-bisexual-transgender watchdog, 69 companies provided their employees with transgender-inclusive health insurance benefits in 2009, including Disney, Wells Fargo, Coca-Cola and Campbell Soup. However, the vast majority of employers and health insurance companies do not offer this type of policy.
“If it was more reasonable, I don’t see why anyone would go through the black market,” says Flynn, who is now 68. “I fell between the cracks. But we’re sort of like the forgotten people. We’re on the cusp, and we have to take what we can get.”
Jeri Hughes of Transgender Health Empowerment Inc., says that most health-care companies won’t pay for transition-related care. “The bottom line is, some policies exclude anything that has to do with gender identity,” she says. “They won’t pay for hormones, anything, even if a doctor prescribes it.”
Susan Pisano, vice president of communications for America’s Health Insurance Plans, or AHIP, which represents 1,300 health insurers and 200 million Americans, says the country’s health insurance crisis is the main reason most health care providers can’t insure transition-related care.
“Difficult decisions are made every day about what to cover and what not to cover,” she says. “Companies are not going to be able to afford insurance for every possibility. The rising costs of health care make it hard to afford coverage for the things that are covered.”
Mara Keisling, executive director of the National Center for Transgender Equality, says that the lack of health care coverage means that more and more transgender people are forced to seek out dangerous procedures. “If the health care system doesn’t work around the patient, the patient will work around the health care system,” she says.
Keisling says health insurance companies sometimes interpret the exclusions to mean any sort of care for transgender people. “Often, the exclusions are interpreted to mean any kind of sex-related care, such as mammograms or gynecological exams for transgender men,” says Keisling. “I am currently working a case for a transgender woman who is a federal employee. Her doctor ordered a blood test for anemia and the insurance company refused to pay for it because it was transgender blood.”
Peter Sprigg, Senior Fellow for Policy Studies at the Family Research Council, a Christian organization that lobbied against including transition-related surgeries in the Affordable Care Act, says that transition-related care is not medically necessary. “We don’t believe that taxpayers should be asked to pay for elective surgery, and we believe that sex-change surgery is the ultimate form of elective surgery,” says Sprigg.
Sprigg says that the Family Research Council considers transgender people to be suffering from a mental disease or disorder. “The appropriate treatment for gender identity disorder is psychological therapy to conform their subjective mental state to the objective reality of their biological sex,” he says. Sprigg cites a 1979 Johns Hopkins University study by Jon Meyer and conservative Catholic Dr. Paul McHugh that found there was no real benefit to gender reassignment surgery as evidence.
But Dr. Heino F.L. Meyer-Bahlburg’s 2009 article for the American Psychiatric Association, “From Mental Disorder to Iatrogenic Hypogonadism: Dilemmas in Conceptualizing Gender Identity Variants as Psychiatric Conditions,” found that “McHugh’s etiologic formulations are not based on solid empirical evidence, and that the pessimistic evaluation of SRS outcome is not shared by follow-up studies.”
Dr. Harold Reed, an urologist and gender reassignment surgeon, says it’s not just a matter of insurance companies covering transition-related care, but paying the doctors enough to perform the surgeries. “One sphere is not just to get insurance companies to recognize and cover it, but if they’re not providing the doctors reasonable compensation, no doctors will want to do the surgeries,” he says. “We can’t neglect these people. We can’t turn our backs on them when they have support from their therapists and doctors.”
Mason Davis, executive director of the Transgender Law Fund, says the government shouldn’t dictate health care decisions. “In the end, I think even the Family Research Council would agree that bureaucrats shouldn’t be making decisions about health care,” he says. “That decision should be made between a doctor and their patient.”
Davis says that covering transition-related surgeries wouldn’t be a huge strain on taxpayers. “What’s important to remember is that there really aren’t many of us, and we’re not that expensive,” says Davis, who is a transgender male. “We’re better off having people get their health care from the system, not on the streets.”
NOTE: This post has been updated to correct the spelling of the last name of the executive director of the National Center for Transgender Equality. It is Keisling, not Kiesling.